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Funshine Summer Program 2014 Registration Form Child’s Name: Gender: F / M Age: Birth Date: Parent’s Name: Address: Home Phone: Employer Name: Address: Work Phone: E-mail: Fax or Pager: Cell: Parent’s Name: Address: Home Phone: Employer Name: Address: Work Phone: E-mail: Fax or Pager: Cell: Child’s Primary residence is with: □ Both Mother and Father □ Mother □ Father □ Other STATEMENT OF HEALTH To the best of my knowledge, my child is in good health condition and all child hood immunizations are current. Please Print Parent Name Parent Signature Date Sign In and Sign Out My child has permission to: □ Sign In and Out without an adult (walk/bike) □ Adult Sign In/Out Only (unfamiliar adults must present ID to staff) FUNSHINE EMERGENCY CARD 2014 Child’s Last Name Child’s First Name Birth Date Child’s Primary Address City Zip Code Home Phone # Parent Name Home Phone# Alternate Phone # Parent Name Home Phone # Alternate Phone # Auth. to Pick Up/Emergency Contact Contact Address Contact Phone Auth. to Pick Up/Emergency Contact Contact Address Contact Phone Auth. to Pick Up/Emergency Contact Contact Address Contact Phone Health Concerns, Allergies, Behavioral Concerns, etc. ---PAGE BREAK--- Please INITIAL the following categories to indicate that you have read and fully understand each item. All items must be agreed to for your child to participate in the program. I have read the Parent Handbook and have discussed relevant areas with my child. I understand and agree to the conditions initial and policies covered within. I understand that Funshine will take field trips away from the school site. Field trip attendance is not mandatory; however, I initial understand that activities/supervision will not take place on site if I choose for my child not to attend. I understand that my child must wear the official summer camp t-shirt on all field trip days. I give permission for my child to be transported by school bus, recreation center vans or by foot to attend swimming activities, field trips or local park outings. I give permission for my child to participate in all indoor and outdoor activities, initial I give my child permission to watch the occasional movie. I understand the movies will be rated G or PG. I may refuse to initial allow my child to view any movies and they will be provided with an alternative quiet activity. I give permission for my child to be photographed or video taped during the program that may be used to promote Brighton initial Parks and Recreation. I understand that there will be no compensation provided for the use of these materials. I agree to notify the program leaders in writing of any changes in my child’s program schedule, including tardiness or initial absence. I will apply sunscreen to my child before arriving to camp and will provide sunscreen in my child’s backpack labeled with initial their first and last name. I give permission for staff to re-apply sunscreen. I will send a refillable water bottle labeled with my child’s first and last name in my child’s backpack every day. initial Staff may inspect children’s possessions if necessary. initial I give my permission to the City of Brighton Funshine Summer Program to transport my child to the nearest medical facility initial in case of serious illness or injury and to secure emergency medical treatment. I have read the Parent Code of Ethics and will support Funshine Staff by creating a positive relationship with them and initial my child. FUNSHINE EMERGENCY CARD 2013 Physician Name Address Phone # Dentist Name Address Phone # Hospital of Choice Address Recreation Center [PHONE REDACTED] Medical Insurance Co. Group/Policy # Medications being taken Height Weight Eye Color Hair Color I give my permission to the City of Brighton Funshine Summer Program to transport my child to the nearest medical facility in case of serious illness or injury. Parent Signature and Date I give my permission to the City of Brighton Funshine Summer Program to secure emergency medical/surgical treatment. All expenses for care will be covered by the parent/guardian. Parent Signature and Date